The focus of this blog is on the wonders of government-run health-care everywhere but I also note the damage done to private medicine by a legal system that supports predatory litigation.

The long-established socialized medicine systems in Britain and Australia are a particularly relevant warning about where such systems end up.

Posts by John J. Ray (M.A.; Ph.D.)

Tuesday, January 31, 2006

"EQUALITY" IN BRITAIN'S SOCIALIZED HEALTH-CARE SYSTEM

Equality always was a myth in British health care (well-connected people have always got their services promptly) and it is steadily getting more so. But at least now Brits don't have to go abroad for prompt health care

National Health Service patients are paying for enhanced levels of care and operations that are no longer available free at hospitals across England. The superior treatment for fee-paying NHS patients has been criticised as creating a two-tier health service and privatisation by stealth. This week an NHS trust in Yorkshire will become the latest to offer the service, with a new dermatology clinic performing operations that were once free of charge on patients who are prepared to pay. The operations will be carried out in an NHS hospital by NHS doctors and nurses during NHS time.

The growth in add-on services has alarmed some experts. Professor Allyson Pollock, director of the Centre for International Public Health Policy at Edinburgh University, says the most vulnerable patients are suffering as a result of fees being widely introduced. “It is shocking that NHS patients can pay for a higher level of care. They are getting priority treatment and are able to pick and choose,” said Pollock.

The Foundation Skin clinic, to be opened by Harrogate and District NHS Foundation Trust, has been described by managers as a “halfway house” between state and private care. NHS patients will be able to pay the trust to remove moles and warts, to screen moles or to have Botox injections to reduce heavy sweating. Some of these services were offered free by the trust until 2003, when it stopped paying for them. The new rates will be lower than those charged by private hospitals, however. The trust admits that the clinic has been set up in response to NHS funding shortages and said patients are happy to pay for treatments no longer available for free. Dr Kay Baxter, consultant dermatologist at the trust, said: “This clinic has been developed to fill a genuine gap in patient service. A local cosmetic exclusion policy has been in place since early 2003. “The NHS currently faces many difficult decisions with regard to the funding of treatments. Our patients are very understanding of the reasons behind the cosmetic exclusion policy. They are pleased to be able to access treatment not ordinarily available on the NHS while supporting their local health service.”

Many other NHS trusts across England are now charging patients for treatments or levels of care that would previously have been free. Patients giving birth at Queen Charlotte’s and Chelsea NHS hospital in London can secure one-to-one treatment from a midwife if they pay 4,000 pounds, under the new Jentle Midwifery scheme. One-to-one midwife care is the recommended standard of treatment and has been shown to reduce the need for medical interventions. It is not available to all women because of a shortage of midwives. The Hammersmith Hospitals NHS Trust, which runs Queen Charlotte’s and Chelsea, says revenue from the scheme, which has so far been used by 74 women, goes back into the NHS and has already paid for 2½ midwives’ salaries

For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.

Monday, January 30, 2006

Brits acknowledge the limits of State control of medical services

They're so desperate they are clutching at any hope

Ministers are hoping to rescue the NHS from its continuing cash problems through a "semi-privatised" scheme that trains patients to avoid hospital or their GP. The Expert Patient Programme, which has cut hospital visits by 16 per cent in trial areas, is to have its budget tripled before becoming a not-for-profit company, The Times understands.

Details of the "flotation" will be carried in a make-or-break White Paper on patient care outside hospital to be published this month.

Patricia Hewitt, the Health Secretary, wants the White Paper to spell out how the NHS will reduce demand for the most expensive form of treatment - in hospitals. Training patients how to "self-care" will be at the core of the proposals. Although the cost savings for hospitals and GPs would be several years down the line, the change in emphasis to self-care is one reason why some of the biggest hospital-building schemes in the NHS are now under review. Ms Hewitt believes that the best way to expand the Expert Patient Programme rapidly is by allowing NHS managers or outside providers to take it over from state control. She is expected to pave the way by increasing the budget from 6 million pounds a year to 18 million pounds.

The programme works by running training courses for patients with chronic conditions such as diabetes, asthma, multiple sclerosis and arthritis. They learn how to treat themselves when previously they would have gone to their doctor or the hospital accident and emergency department, and to avoid such emergencies altogether by looking after themselves better.

The programme, set up four years ago, was based on an American "self-care" plan devised to save on the astronomical costs of US hospital care and was tested in various areas of Britain. Six months into the trials, GP consultations fell by 7 per cent, while local outpatient visits and emergency care attendances dropped by 10 per cent and 16 per cent respectively. Hospital admissions among those on the scheme were also reduced by 13 per cent. Patients said that they became better at controlling symptoms, more confident, and better at using information from books and support groups.

A senior NHS source said that, despite initial concerns from some GPs, ministers were impressed with the benefits to patients as well as potential cost savings. The source added: "The Expert Patient Programme is an excellent example of how the NHS is changing the way it works with people with long-term conditions. We want to build on this experience as part of expanding and developing self-care. "We want the EPP to help more of the 17 million people in England with long-term conditions so that more people understand and can do more to manage their own conditions."

For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.

Sunday, January 29, 2006

THE BRITISH MONEY SINK

The more money British public hospitals get, the LESS they are able to do their job

The full scale of the crisis facing the NHS was laid bare last night by ministers who admitted that up to 50 trusts had lost control of their finances. Patricia Hewitt, the Health Secretary, "named and shamed" 18 NHS trusts who have plunged into substantial deficit and will now have outside accountants imposed on them to find millions of pounds of savings. A further 32 organisations will be given additional "advice and management support", while another 19 needed "drive and focus" to meet their financial targets.

Her comments came as a survey of hospital managers found that more than three quarters of NHS trusts currently in deficit have cut staff, 52 per cent have closed wards while 48 per cent are delaying work, and another 38 per cent have cancelled services or restricted eligibility for services.

Ms Hewitt admitted that it was a "difficult and anxious time" for NHS staff as years of huge financial generosity ended with the health service last year recording its first financial deficit since 1999-2000. At 76.4 billion pounds, the NHS budget is now larger than the gross domestic product of 155 members of the United Nations, she said. "It is one of the largest and most complex organisations in the world, and three quarters of trusts have delivered improvements within their budget."

The NHS Confederation, which represents managers, yesterday gave warning that the financial problems were undermining public confidence. "It is wrong of the Government to simply blame NHS managers" said Gill Morgan, the confederation's chief executive. "The causes of the current problems are deep-rooted and long-term." They would never be resolved until politicians allowed NHS managers to "make some painful decisions" - such as closing hospitals or reducing the number of beds. "A fixation with buildings is preventing the development of new and imaginative services," she said.

Andrew Lansley, the Shadow Health Secretary, said: "We warned that ministers had lost financial control and Ms Hewitt's statement confirms this is the case. "There are clearly systematic problems because at the same time as resources to the NHS are increasing dramatically, costs have ballooned. "Instead of the Department of Health blaming trusts, Patricia Hewitt should come to Parliament and make a full statement on the financial prospects for the NHS, for this year and the coming financial year".

Yesterday she declined to say whether the most recent figures showed any improvement in financial performance.

Free film here: "Dead Meat is a short film which shows the reality of health care under Canada's socialized medical system: Canadians wait ... and wait. And sometimes - they die while waiting for free government health care. Filmmakers Stuart Browning and Blaine Greenberg are currently in production on a feature-length film exploring health care in the U.S. and Canada slated for release in late 2006. As an interim offering, they have produced this short.

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For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.

Saturday, January 28, 2006

Demanding the Impossible From Our Health Care

Almost everyone agrees that we ought to ``fix the health care system'' -- a completely meaningless phrase despite its popularity with politicians, pundits and ``experts.'' Indeed, it is popular precisely because it is meaningless. The people who proclaim it rarely tell you the discomforting choices it might involve. Instead, they focus on a few specific shortcomings of our $1.9 trillion health-industrial complex and imply that, if we correct these often-serious flaws, we'll have ``fixed'' the system or at least made a good start. This is rarely true, and so most forays into ``health reform'' end with disillusion.

We are about to start the cycle again. By most accounts, President Bush plans to highlight health care in his forthcoming State of the Union address. His proposals may or may not have merit, but they surely won't fix the health system in any fundamental way. The reason is that most Americans don't want to fix the system in that sense. Most are satisfied with their care. Most don't see (or pay directly) most of their costs. Because politicians -- of both parties -- reflect public opinion, they won't do more than tinker. Unfortunately, tinkering isn't enough. As everyone knows, health spending has risen steadily. In 2004, it totaled 16 percent of national income, up from 7.2 percent in 1970. As health insurance becomes more costly, the number of uninsured, now about 46 million, may grow. Worse, health costs may depress wage gains, raise taxes and squeeze other government programs.

Here's the paradox: A health-care system that satisfies most of us as individuals may hurt us as a society. Let me offer myself as an example. All my doctors are in small practices. I like it that way. It seems to make for closer personal connections. But I'm always stunned by how many people they employ for non-medical chores -- appointments, record-keeping, insurance collections. A bigger practice, though more impersonal, might be more efficient. Because insurance covers most of my medical bills, I don't have any stake in switching.

On a grander scale, that's our predicament. Americans generally want their health-care system to do three things: (1) provide needed care to all people, regardless of income; (2) maintain our freedom to pick doctors and their freedom to recommend the best care for us; and (3) control costs. The trouble is that these laudable goals aren't compatible. We can have any two of them, but not all three. Everyone can get care with complete choice -- but costs will explode, because patients and doctors have no reason to control them. We can control costs but only by denying care or limiting choices.

Disliking the inconsistencies, we hide them -- to individuals. We subsidize employer-paid health insurance by excluding it from income taxes (the 2006 cost to government: an estimated $126 billion). Most workers don't see the full costs of their health care. Nor do Medicare recipients, whose costs are paid mainly by other people's payroll taxes. We're living in a fantasy world. Given our inconsistent expectations, no health-care system -- not one completely run by government or one following ``market'' principles -- can satisfy public opinion. Politicians and pundits can score cheap points by emphasizing one goal or another (insure the uninsured, cover drugs for Medicare recipients, expand ``choice'') without facing the harder job: finding a better balance among competing goals.

Every attempt to do so has failed. Consider the ``managed care'' experiment of the 1990s. The idea was simple: herd patients into health maintenance organizations or large physician networks; impose ``best practices'' on doctors and patients as a way to encourage preventive medicine and eliminate wasteful spending; and cut costs through administrative economies. But managed care upset doctors and patients. After a backlash, managed care relaxed cost controls.

Now, some say that because the ``market'' has failed, greater government control is the answer. Private insurance has high overhead costs and generates too much paperwork. True. Still, there's not much evidence that over long periods government controls health spending any better. From 1970 to 2003, Medicare spending rose an average of 9 percent annually. In the same years, private insurance costs rose 10.1 percent annually.

Americans want more health care for less money, and when they don't get it, they indict drug companies, insurers, trial lawyers and bureaucrats. Although these familiar scapegoats may not be blameless, the real problem is us. We demand the impossible. The changes we truly need are political. We need to reconnect people with the public consequences of their private acts. We should curb the subsidization of private insurance. Medicare recipients should pay more of their bills. But these changes won't happen because people don't want to see the costs. We don't have the health-care system we need, but we do have the one we deserve.

More fallout from the closure of emergency services at Caboolture hospital

A fire crew was dispatched to give urgent first aid to a Bribie Island man who had a heart attack because ambulances were busy transporting patients away from the troubled Caboolture Hospital. Fire officers gave oxygen for almost 1 1/2 hours to retired NSW police officer John Kenny, 57, until an ambulance was available. As well as having to wait for an ambulance, Mr Kenny was diverted away from Caboolture Hospital's emergency department which normally would have treated heart attack victims in the area.

A Queensland Ambulance Service spokesman last night confirmed a fire truck had been sent to Mr Kenny because it was "an unusually busy night". He denied ambulance crews had been busy diverting patients from the Caboolture Hospital. "Every available crew in the area were on a code-one emergency response," he said. "It was just an unusually busy period at that stage. "We responded with a firefighting crew who all have advance first-aid and lifesaving equipment on their trucks. "While it doesn't happen very often, we do have a standing agreement with the fire service to do this sort of thing. They are a great back-up. It is better having someone with advanced first-aid and life-saving equipment than no one at all." The spokesman said that at all times ambulance officers were in contact with Mr Kenny and the fire officers treating him.

Mr Kenny said he telephoned for the ambulance at 3am on Saturday and was shocked 10 minutes later to hear a fire engine siren outside and four fire officers walking into his home. "They put me on some oxygen and said there were no ambulances available," Mr Kenny said last night. "I didn't believe it. I thought someone was playing a bad joke on me. It took an ambulance an hour and a half to get there. "In the end an ambulance came from Caboolture station. They said they were spending all their time running people around the place because there is no Caboolture Hospital."

Mr Kenny has been in Brisbane's Prince Charles Hospital waiting for an angiogram since Saturday morning. He said the person he was sharing his room with had been waiting for most of that time for a 10-minute stress test which he was unlikely to get before Friday. "I moved here seven years ago and I remember (Premier) Peter Beattie saying we've got the best hospital system in the world. It's world-class," Mr Kenny said. "It might have been then, but, by God, it's not now. "You can give the firies and the ambos a real wrap. But you can give the people running the place -- the State Government -- the thumbs-down."

A spokeswoman for Mr Beattie said last night the Premier was unable to comment until he had been briefed on the circumstances. Opposition health spokesman Bruce Flegg said the incident showed other emergency services were being drawn into the problems confronting the state's public health system. "Heart attack carries with it a very high risk of sudden death," Dr Flegg said. "Failing to dispatch the properly equipped ambulance and paramedics increases the risk the patient will not survive." He said the failure to send an ambulance was compounded by the fact that the nearest hospital, Caboolture, was not taking patients such as Mr Kenny.

For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.

Friday, January 27, 2006

ATTACK GOVERNMENT HEALTH-CARE REGULATION, NOT WAL-MART

Government is little more than a coercive transfer machine. If you can't acquire something through consent and exchange, you ask politicians to compel others to provide it. This goes on every day. Never was it more blatant than when the Maryland legislature passed a law to compel Wal-Mart to spend at least 8 percent of its payroll on health benefits or pay tribute to the state's welfare system.

The Maryland legislature did not name Wal-Mart in the bill. It imposed its requirement on all companies with more than 10,000 employees. But everyone knew that only Wal-Mart was affected. Of companies in the state with more than 10,000 employees, only Wal-Mart (with 17,000 at 40 stores) spends less than 8 percent on health insurance. (It reportedly spends close to that percentage.) Moreover, the most active backers of the bill were organized labor, which would like to unionize Wal-Mart employees, and the retailer's biggest rival in the grocery business, Giant Foods, which is already unionized.

Whatever one thinks of Wal-Mart (it really should disavow eminent domain), when government tampers with prices and wages, bad things happen to the supposed beneficiaries. If the law compels a company to provide health insurance, it will most likely do one or more of the following: hire fewer employees, lay off employees, reduce future cash wages, open fewer stores, or close stores. If someone works at Wal-Mart we can assume that, in his or her judgment, the job is the best available option. Anything else will be no better than second best. Wal-Mart has to pay what it takes to attract and keep good employees, consistent with keeping prices low. So, generally speaking, under current conditions the retailer pays its employees market-determined wages, which ultimately are set by consumer demand.

This is not to say that the market is free, that employees have the full range of opportunities they would have if it were, or that Wal-Mart does not benefit from government favors. Far from it. Taxes and regulation take a greater toll on small competitors, potential competitors, and would-be self-employers than on big companies. This reduces workers' options. It's not impossible for a small company to grow big (Wal-Mart did it); but it is harder than it would be in an unfettered marketplace. Still, market forces operate to some extent.

Companies don't scrimp on medical benefits because they are stingy. They do so in part because medical care is increasingly expensive and workers may prefer cash to insurance. Government intervention is the reason. The best way to make health coverage cheaper is for government to quit inflating the price of medicine through burdensome regulation and competition-throttling licensing. As medical costs came down, so would the price of health insurance.

But we should go further. Were it not for the income tax there would be no good reason for employees to tether themselves to their bosses with health insurance. Better to take your compensation in cash and buy the health coverage best for you, than to let your employer make the decisions. But the tax laws push many people into often-lavish employer-provided insurance. This raises the price of medical care, pricing other people out of the market and leading to problems like "job lock," in which workers are afraid to change jobs because it might mean adverse changes in coverage. Working for someone else can be unpleasant enough. Why mix health insurance into the relationship?

Once again politicians have tried to fix a problem that they helped cause. The same people who made health insurance artificially expensive by mandating coverage for services most people don't want now are trying to force Wal-Mart to clean up their mess. When will they learn that, as Henry David Thoreau put it, "this government never furthered any enterprise but by the alacrity with which it got out of the way"?

A better example of the perverse incentives and absurd results of government micro-management came to light last week in Maryland, where a few well-placed geniuses decided they were going to endanger thousands of jobs in their state in order to make a point. Democrats, who completely dominate the state House and Senate in Annapolis, overrode Gov. Bob Ehrlich's (R) veto of a bill requiring any business with more than 10,000 employees in the state to spend on health care an amount equal to 8% of its payroll. Wal-Mart has 16,988 employees in Maryland, and it is the only private corporation that meets the 10,000 threshold. For that reason, the bill is widely known as "the Wal-Mart bill."

Regardless of how you feel about Wal-Mart, this bill is just plain stupid, and in too many ways even to explain in a 1,000 word column. But here are just a few of the absurdities that could result:

* If Wal-Mart fires or relocates 6,989 Maryland employees, it will immediately be in compliance with this law. Maryland is a small state with lots of border, and a few stores just across the Delaware line could continue to serve many Maryland customers, without the burden of Maryland's sales tax.

* Likewise, if Wal-Mart dismisses 6,989 employees and hires them back as independent contractors, it could skirt the new law and, in fact, avoid paying those workers any health benefits whatsoever or even payroll taxes.

* Wal-Mart could also comply with this law by reducing its employees' salaries, but spending the same amount it does now on health care, as long as the latter number comes out to 8% of the former.

The stated reason for this bill is that Wal-Mart pays its workers so little that they cannot afford the company health plan, which is inexpensive if minimal. This ends up costing the state when Wal-Mart workers sign up for Medicaid. Entirely aside from the fact that this is a problem of Maryland's welfare generosity more than Wal-Mart's stinginess, Maryland is getting the better end of this deal. According to its web site, Wal-Mart paid $112.2 million in Maryland sales taxes and $13.2 million in other state and local taxes in 2004. It also employs thousands of Marylanders directly and tens of thousands of others indirectly through its dealings with in-state vendors -- and they all pay state taxes too.

Wal-Mart's full-time associates in Maryland make an average of $9.97 per hour, plus a four percent contribution to their 401k. It's not a great package -- it comes out to about $21,000, plus an occasional bonus -- but there's more to the story than that number alone. The lower-paying Wal-Mart jobs attract those who would have trouble getting a job that pays more -- young people getting a first job, poor and unskilled workers, and recent immigrants (including illegal ones, as the government discovered last spring). Moreover, Wal-Mart says that 220,000 of its 1.3 million workers in the U.S. are older than 55, suggesting that many employees are looking to supplement their retirement. The workforce is also disproportionately female (775,000 women work for Wal-Mart), suggesting that a Wal-Mart income may be a second income for many families.

If Wal-Mart scales back its presence in Maryland because of the state legislature's hostility toward businesses, it is the workers and the unemployed who will suffer. Until this bill passed, Wal-Mart had been planning to build a distribution center in economically depressed Somerset County, on Maryland's Eastern Shore. The facility would have brought 800 jobs to the area. The company may now decide to relocate a few miles in either direction, either to Delaware or to peninsular Virginia, both of which are nearby.

So you might say that this law hurts those it is intended to help. But you would be wrong. The Wal-Mart bill was never intended to help the workers at Wal-Mart. It is intended to help Democrats and labor unions. This bill is part of a nationwide campaign by labor unions to recover their rapidly declining share of the U.S. labor market. In 1945, unions represented 35% of the labor force. Today they have fallen to 12.5%. In the private sector, unions represent a mere 7.8%, and they have become desperate for more members. In recent years, they have tried, in vain, to find fresh blood by opening into new sectors of the economy. Wal-Mart is big enough to qualify as its own sector of the economy, meaning that if the unions can get a toe-hold in its stores, they will have an excellent crack at the company's million-plus employees, plus a good shot at creating closed shops in some states.

Most Democratic politicians would lose their jobs if unions stopped contributing millions of dollars for political campaigns and thousands of bodies on Election Day. The decline of unionism has been disastrous for the Democrats, and its resurrection would be a political boon. For that and no other reason did the Maryland legislature pass this bill, and for the same reason they will try it in other states as well. The United Food and Commercial Workers Union, which has been unsuccessful in unionizing any Wal-Mart workers to date, will continue to harass Wal-Mart until it capitulates.

In Big Labor's war against Wal-Mart, "collateral damage"--in the form of lost jobs and income for the poor--is starting to add up. Of course, since the unions and their legislative allies claim that their motive is to liberate people from exploitation by Wal-Mart, these unintended effects are often ignored. Here in Maryland, however, that's getting hard to do. The consequences of our Legislature's override of Republican Gov. Robert Ehrlich's veto of their "Fair Share Health Care Act" on Jan. 12 will be tragic for some of the state's neediest residents. The law will force companies that employ over 10,000 to spend at least 8% of their payroll on health care or kick any shortfall into a special state fund. Wal-Mart would be the only employer in the state to be affected.

Almost surely, therefore, the company will pull the plug on plans to build a distribution center that would have employed 800 in Somerset County, on Maryland's picturesque Eastern Shore. As a Wal-Mart spokesman has put it, "you have to take a step back and call into question how business-friendly is a state like Maryland when they pass a bill that . . . takes a swipe at one company that provides 15,000 jobs."

Unfortunately, in Somerset, the new law looks more like a body blow than a "swipe." The rural county is Maryland's poorest, with per capita personal income 46% below the state average and a poverty rate 130% above it. Somerset's enduring problem is weak labor demand that greatly limits its 25,250 residents' economic opportunities. There are just 0.8 jobs per household in Somerset, barely half the 1.5 figure that applies to the rest of the state. Somerset's top 10 list of employers features sectors like food services (average annual compensation per employee: $9,637), poultry and egg production ($14,320) and seafood preparation and packaging ($19,190).

It is hard to exaggerate how much the planned distribution center might have meant to Somerset's economy. Using an input-output model, we forecast the "ripple effects" of the new income and spending that could have emanated from Wal-Mart's facility as follows:

* The center's 800 employees would have created an additional 282 jobs among "upstream" suppliers and "downstream" retailers and service establishments; all told, the center would have boosted county employment by 14% and private-sector employment by 20%. * Total annual employee compensation in Somerset would have risen by $46.5 million, or 19%. * Annual output (or "gross county product") would have risen by $128.3 million, or 19%. * State and local tax receipts would have increased by $19.2 million annually; this would include $8.5 million in property taxes, $5.6 million in sales taxes, and $1.4 million in personal income taxes.

Those losses, though dramatic, probably understate the full extent of the damage in this case. They do not include forgone employment and income from construction of the facility and related infrastructure improvements. What is more, Wal-Mart's tentative plans for a second distribution center in Garrett County, in mountainous western Maryland, also appear dead. Garrett, with a poverty rate that is 70% above the state's, is only slightly better off than Somerset

How could our legislators turn a blind eye to such areas? Partly, of course, they are simply eager for Big Labor's votes and money and therefore subservient to its interests. The Service Employees International Union actually helped draft what became known as the "Wal-Mart bill." Unable--so far--to organize workers at the company, the union's immediate national strategy is to limit Wal-Mart's competitive reach by raising its costs. Maryland was a shrewdly chosen place to kick off this campaign. Some estimate that as much as a third of the state's economic activity stems from federal employment and purchases. Over 150,000 Marylanders--six times the population of tiny Somerset--are on the federal (nonmilitary) payroll; they are concentrated in central Maryland, near the nation's capital. Nearly 268,000 more Marylanders draw checks from state and local government.

With so many workers in a sector where revenues appear to arrive automatically and inefficiency never leads to bankruptcy, our state's resulting political culture is quite predictable. Many Marylanders are simply unmindful of the necessities of survival in the private sector: pleasing customers, controlling costs and satisfying shareholders. Thanks to the federal tax dollars collected from the rest of the country and spent in Maryland, the prevailing view of economic reality is inverted: The public sector is seen as the engine of prosperity, with the private one along for the ride.

Reflecting this culture, our legislators often behave as if business is a problem to be solved. On Jan. 17, they also overrode a gubernatorial veto of a $1-an-hour increase in the state's minimum wage. Like the health-care mandate, the hike is a job killer--though not in affluent areas of the state, where strong labor demand long ago pushed the going wage above the minimum. In those areas, the law is largely symbolic and enables well-meaning voters and legislators to conclude that they are "doing something for working families." Safely out of their view, however, at Maryland's impoverished margins, already weak labor demand will be further diminished

What remains to be seen is whether Maryland will be a leading political indicator or an anomaly, for Wal-Mart bills have been drafted in 33 other states. Emboldened by success here, lawmakers in some states have set the threshold for companies to be hit with mandated health benefits as low as 1,000 workers.

In these upcoming battles, legislators should be mindful that companies like Wal-Mart are not the enemy but rather frontline soldiers in a real war on poverty. The profit motive leads them to seek out areas where there is much idle labor and put it to work. Where they are prevented or discouraged from doing so, the alternative job prospect is rarely a cushy spot in the bureaucracy. Rather, it is continued idleness and hardship.

For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.

Thursday, January 26, 2006

It is what it is and it won't change unless staff selection becomes colour-blind and merit-based. But just getting good staff to go there would be a big challenge. Security would certainly have to be good

More than a fifth of the staff at troubled Martin Luther King Jr./Drew Medical Center has been fired or disciplined during the past two years, records show. Serious behavior problems have continued despite intense scrutiny of the hospital by regulators, auditors, consultants, county supervisors and the media. Lapses have included skipping work, sleeping at work, neglecting patients and fighting with other staff, according to records from the Los Angeles County Civil Service Commission.

Despite the ongoing problems, county officials say they believe the disciplinary actions show the hospital is improving. "I really think we're close to being over the hump," said Michael J. Henry, the county's personnel director. The public hospital south of Watts serves a mostly poor, minority community. Regulators have cited it during the past two years for serious patient-care and management shortcomings including several deaths. King/Drew lost its national accreditation and faces the loss of more than $200 million in federal funding if it fails an upcoming inspection.

Since Jan. 26, 2004, King/Drew has disciplined 524 of its roughly 2,500 employees - 199 of whom have been fired or resigned under investigation, Civil Service Commission records show. Two-thirds of the disciplinary actions took place in 2005. Among the deficiencies that led to discipline:

- An on-duty critical-care nurse fell asleep at a break room table while one of her patients faded and died. The nurse and her boss were fired.

- Several janitors urged a belligerent patient struggling with a police officer to "Kick the police's ass." A janitor who challenged the officer was fired.

- A nurse was fired for being absent a total of almost four months between Sept. 1, 2004 and April 30, 2005.

Most disciplined workers appealed their punishments. Appeals by King/Drew workers accounted for one in seven cases filed with the Civil Service Commission last year, compared to fewer than one in 100 in 2002. "We've had some very difficult and lengthy commission meetings as a result," said Z. Greg Kahwajian, the commission president.

For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.

Wednesday, January 25, 2006

U.K.: PUBLIC HOSPITAL SAFEGUARDS IN ACTION

Up to 17 women have been told they are at significant risk of dying from breast cancer after a radiologist wrongly gave them the all-clear, hospital chiefs said yesterday. A report on the work of the radiologist, who has not been named, has found that his diagnoses were not checked by a second radiologist as the hospitals where he worked employed only one. Last night cancer charities called on the Government to provide funding to ensure that all patients referred to hospital by their GP with suspected breast cancer had their scans double-checked as a matter of course.

When the radiologist was previously employed by another hospital, his work was checked by a colleague. The report found that in those cases there was no cause for concern. The doctor was suspended by Trafford Healthcare NHS Trust in April last year after junior colleagues became concerned about the quality of his work and alerted hospital chiefs. The subsequent report, which is published today, identified serious shortcomings which resulted in the recall of 176 patients.

The delays caused by his misdiagnoses could have "significantly altered" chances of survival for 17 patients, a director at one of the hospitals affected said yesterday. One woman's cancer was only noticed two years after the woman was informed that she did not have the disease. Another 16 patients seen by the radiologist at Trafford General and the North Manchester General, both in Greater Manchester, had their conditions misdiagnosed. In total, 2,495 mammograms by the consultant at the centre of the investigation were recalled and rechecked. They dated from April 2003, when he joined the trust.

A small sample of his breast cancer tests were rechecked after concerns were raised. The doctor was suspended at once and checks of all his work carried out by an expert panel. The panel's report states that, of the 176 patients who were recalled because of concerns, 28 women with breast disease were identified whose diagnosis had been delayed as a result of misreporting of their mammograms. Twenty-five were patients from Trafford General Hospital and three from North Manchester General Hospital; 21 had invasive breast cancer diagnosed, six had benign breast disease and one had a treatable tumour.

Delays of more than three months for the diagnosis of breast cancer can have serious implications, but four of the 21 cases had delays less than that period. The remaining 17 had delayed diagnoses of longer than three months. Richard Campbell, medical director at Trafford, said those patients have been told that the delayed diagnosis "might significantly alter their prognosis".

Clara McKay, head of policy at Breast Cancer Care, the leading cancer charity, said that the situation highlighted the need for more radiologists who, where possible, could work in pairs to double-check work. "The standard of all health professionals must be subject to ongoing review," she said. "The acute UK-wide shortage of radiologists must be addressed to ensure reliable breast screening for all."

Dr Campbell said the problem was first spotted by radio-graphers who questioned the radiologist's X-ray work. All his radiology work was subsequently checked but his diagnoses in other areas gave "no significant concern". No problems were reported in his earlier work at another trust, where all breast cancer radiology was double-checked.

Queensland Ambulance will install a third communications system in six years after complaints that unanswered Triple-0 emergency calls led to patient deaths. The computer-aided Premier and Right dispatch systems had become obsolete, with one operator saying they "never did what they were supposed to do". It was expected to cost more than $1 million to set up the new system.

The Sunday Mail revealed this month how a Kilkivan man almost died when the ambulance service ignored his wife's initial call for help. Paramedics were dispatched only after she telephoned a second time, an hour later. Ambulance Commissioner Jim Higgins blamed the delay on a fault with the dispatch system. A communications officer was counselled over the incident, but no details released.

A paramedic who contacted The Sunday Mail this week said bosses were to blame. "The truth is the Queensland Ambulance Service bought a very expensive computer system . . . that was a mistake. It could not do the job and a second system had to be bought," the source said. He claimed staff warned management of the "high probability of error" with the systems. "They should be the ones held accountable, not a poor ambo working the failure-prone system," he said.

Officers had also told of a stoush [fight] between call centre operators in Brisbane and the Sunshine Coast, which they claimed had left critically ill patients to die. The battle related to who should take emergency calls and led to staff being disciplined and fined. An internal service briefing paper leaked to The Sunday Mail revealed Triple-0 calls overflowed from busier communications centres and were "causing difficulties" for smaller centres. The document said 17 per cent of calls were not answered in the first presentation from Telstra. Calls had increased, but staff numbers had not gone up accordingly.

A spokesman for Mr Higgins said the new computer-aided dispatch system would be introduced in ambulance and fire call-centres this year. He said it was an upgrade of systems which would ensure a "cleaner, smoother" operation. The spokesman would not reveal the cost of the new system.

For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.

Tuesday, January 24, 2006

This Cure Is Free!: A Shadeggelic health-care plan

The Republican Congress can't seem to touch health care without making America sick. While Health Savings Accounts are a recent plus, the long-feared Medicare drug benefit premiered January 1 to widespread panic. Seniors are confused and frustrated, while fiscal conservatives stand aghast as tax dollars fly from the Treasury like bats fleeing a cave.

Congress can redeem itself with a simple and cost-free cure rather than an elaborate and expensive complication. The Health Care Choice Act, sponsored by Rep. John Shadegg (R., Ariz.) and Sen. Jim DeMint (R., S.C.), would let American consumers purchase health insurance across state lines, just as they now may shop coast to coast for mortgages.

Shadegg-DeMint would let insurers licensed in one state sell to individuals in the other 49. As such, Congress would use its constitutionally enumerated powers to liberate interstate commerce and transform 50 separate, closed markets for medical coverage into one open, national market for health insurance.

"Two-thirds of the uninsured have incomes below 200 percent of the federal poverty level, and most cite unaffordability as the top reason for why they are uninsured," said Shadegg, who hopes to succeed Rep. Tom DeLay as House majority leader. "Until consumers can purchase their health care like their auto, homeowners, or life insurance, we won't reform health care; we will only re-regulate it."

"Just as Delaware became a magnet for banking, some states will become magnets for health insurance," predicts Dr. David Gratzer, a physician and Manhattan Institute senior fellow, and one of this idea's earliest proponents. "People seem to understand intuitively that it doesn't matter whether their checks come from Delaware or New York or California. Likewise, the issues around health insurance are cost and availability rather than state of origin."

Location matters. A health policy for a single Pennsylvanian costs roughly $1,500 annually. Cross the Delaware into New Jersey, as George Washington did in 1776, and a similar health plan costs about $4,000, thanks to government regulations. "When doctors worsen a patient's condition, we call it an iatrogenic ailment," Dr. Gratzer notes. "We lack an equivalent term for when politicians aggravate a problem."

By mandating benefits, legislators have swelled the standing army of the uninsured. As Victoria Craig Bunce and J. P. Wieske explained in their January 2005 report for the Council for Affordable Health Insurance: "Mandating benefits is like saying to someone in the market for a new car, if you can't afford a Lexus loaded with options, you have to walk." Making every health policy cover acupuncturists, marriage therapists, or in vitro fertilization, as some states do, looks less compassionate when such adornments drive the humble from the market. CAHI estimates that state mandates can hike insurance prices 20 to 45 percent.

"Guaranteed issue" rules, which let people wait until they ail to purchase coverage, also boost prices. Ditto "community rating." It slaps the same government-controlled price on insurance for everyone - young or old, fit or fat - in a given jurisdiction. This is as idiotic as charging 16-year-old boys and 60-year-old widows the same amount for auto insurance.

Economics aside, Dr. Gratzer praises Shadegg-DeMint's clinical potential. "The more people who are covered the better," he says. "That means fewer people hesitate to get tests or follow up with physicians. Eventually, that will lead to a healthier population."

So, what will this cost? Nothing. Unlike nearly every action by this Republican Congress, this legislation expends no tax dollars. Your wallet is safe. For now.

Democrats routinely complain that 45 million Americans lack health insurance. Many are between jobs, young, or more prosperous, and decide to forgo insurance. Still, Democrats correctly call this a serious concern for many Americans. The Shadegg-DeMint proposal could be a key solution to this problem. Democrats should embrace this Republican idea. If they rather would deny the uninsured an expanding array of lower-cost health-coverage options, let them stand up this election year and say so.

AMAZING! GOVERNMENT FINDS THAT CUTTING THE NUMBER OF HOSPITAL BEDS CREATES BED SHORTAGES

It takes a government to need years to find that out

Health bureaucrats have been ordered to open every available hospital bed as the State Government struggles to overcome the "access block" problem choking emergency departments. The order has come with an admission by Premier Peter Beattie that planners were wrong to downsize major hospitals during redevelopments in the 1990s. Mr Beattie returned from his three-week annual holiday yesterday to issue a 10-point plan to combat statewide doctor shortages in the short term....

It commits $3 million to find ways to ease "access block", whereby the lack of available beds or medical treatment prevents patients from being moved out of emergency departments. "In addition, this week every hospital in Queensland will be instructed by the director-general to investigate how many beds it can open to assist with solving 'access block' across the Queensland health system," the plan says.

Mr Beattie said there was "capacity in the existing hospitals" to open more beds, but admitted his and previous governments had erred in reducing the number of beds in major hospitals. The Opposition said the Government eliminated about 600 beds when it redeveloped the Princess Alexandra and the Royal Brisbane hospitals as part of its capital works agenda in the late 1990s. At the time, the Government said fewer beds would be needed because future health care models would allow more day surgery and extra-mural treatment.

But Mr Beattie yesterday said the patient care model used to determine bed numbers then was wrong. "I think there were major flaws in the model . . . and the advice that we're now getting 15 years later is different to what it was 15 years ago. And I think we should be upfront about that."

There is a joke just up on Wicked Thoughts that readers here may find amusing.

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For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.

Monday, January 23, 2006

Choice on the sickbed

New Labour's new Patient Choice initiative suggests it doesn't know the meaning of the c-word

You may be part of the 80 per cent of the British public who didn't know this, but as of 1 January this year we Brits have the right to choose between at least four hospitals for non-emergency treatment.

Under health secretary Patricia Hewitt's Patient Choice initiative, which she modestly describes as a 'revolution', you will no longer have to put up with treatment at your run-down, resources-challenged local hospital - you can choose a different run-down, resources-challenged hospital in your Strategic Local Authority instead. The only problem is, a Mori poll carried out for the Department of Health found that of 1,276 people surveyed 41 per cent knew 'nothing at all' about the new policy and 39 per cent said they knew 'just a little'. Only four per cent said they knew a 'great deal'. And given that the NHS is one of the biggest employers in Europe, that four per cent may well be its own staff.

Welcome to Britain 2006, where a 'revolution' can occur without anybody noticing and where you can have apparently brilliant brand new choices without even knowing it; where the government's idea of overhauling the NHS is to let us pick between hospitals rather than to rethink the hospitals themselves. Nothing better captures the government's degraded view of choice than the 'empowering patients' debate. Under New Labour choice has come to mean, not active citizens making decisions about big issues, but sick people deciding whether they want their injections or stitches from Dr Patel or Dr Jones in hospital A or B (or C or D, to be fair). It says a lot about the government's view of citizens that it only seems able to conceive of us as choice-makers when we're dilapidated, and temporarily removed from public life to get something fixed.

Government ministers present choice-in-health as something that patients are crying out for and which they are graciously providing. According to Hewitt, 'Every survey shows people want more choice and control over healthcare. We found the majority welcome being offered a choice and use that choice.' In truth, patient choice is an entirely top-down initiative; it's a political invention. How many people do you know who when they get sick think to themselves: Right, I must flick through the catalogues and go on a tour of hospitals in and around my area to find out which has the best resources and doctors? When we're ill we want to be made un-ill as quickly as possible, preferably in a local hospital that does things competently. For most people, hospital treatment is a technical thing rather than a life-changing choice: we want to be made better so that we can get on with the important things in life.

Indeed, choice in healthcare is something of a misnomer. Most of us are not in a position to make serious choices about the treatment we receive because we don't know enough. As Barry Schwartz, author of The Paradox of Choice, argues, 'individuals are not in a position to accept responsibility for their medical treatment' because we generally do not know 'the ins and outs' of such matters. It is precisely when we're sick or injured that we are most willing to absolve ourselves of decision-making and hand our bodies over to the experts. We trust doctors to choose what treatment we need because they know better than us. One satire website summed up the absurdity of too much choice in healthcare with the headline 'New NHS reform allows patients to choose own diagnoses..'

Something that we could take responsibility for is rethinking how the NHS is run - but if this isn't really a personal choice over treatment then neither is it a political debate about healthcare. 'Patient choice' never refers to making choices about how public healthcare is organised and distributed; instead it's limited to choosing between different hospitals within an already-defined healthcare system. Indeed, the government's emphasis on patient choice seems designed to avoid having any kind of proper debate. By making choice of hospitals the priority Hewitt and co are really saying: 'Yes, we know some local hospitals are crap. But there isn't much we can do about it, so from now on you can choose a different hospital instead.' Giving us more choice over which hospital to have our kidney op in is another way of limiting the debate about hospitals and healthcare more broadly. Instead of having a say in how the healthcare system might be reshaped, we're given leeway to wander around the current healthcare system a bit more than we could before.

Hewitt's revolution really amounts to a choice between venues. We will receive much the same treatment for the same ailment, but in one of four buildings of our choice. This is choice in the consumerist rather than the political sense. Our medical treatment is necessarily a set course of action, and it seems that political decision-making about the NHS is off the agenda, so our choice is only over where that action should take place. Like consumers in the supermarket we can pick already-made products off the shelf; how those products got to be made and put on the shelves is something for other people to concern themselves with, apparently. I prefer the late social theorist C Wright Mills' definition of choice: 'Freedom is not merely the opportunity to do as one pleases; neither is it merely the opportunity to choose between set alternatives. Freedom is, first of all, the chance to formulate the available choices, to argue over them - and then, the opportunity to choose.'

Hewitt's Patient Choice initiative is really an attempt to tart up the NHS with some positive-sounding words (or 'Hooray Words' as Jamie Whyte calls them in his book A Load of Blair). Bereft of ideas for how to improve the NHS the government simply plays around with its presentation. This could end up making things worse by increasing the bureaucracy. As one doctor said when asked for his response to the choice revolution: 'At the present time we're still, to be honest, pretty short of doctors, nurses and other health professionals to run a high-quality 21st-century health service.' (5) Maybe the government should put its thinking cap on about those problems instead of giving us bogus choices we never asked for in the first place.

For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.

Sunday, January 22, 2006

HOW SOCIALIZED MEDICINE HELPS THE POOR

Australia's public hospitals show the way

Surgeons are being prevented from performing operations on poor people in public hospitals because of budget constraints, the Royal Australian College of Surgeons said yesterday. The college made the claim when rejecting Productivity Commission proposals which would overhaul medical training and pass some doctor roles to nurses and other health workers. The commission said the health system was inefficient and needed to be restructured to ease shortages in the medical workforce.

The Australian Physiotherapy Association yesterday backed the commission's report. But Royal Australian College of Surgeons president Russell Stitz said the recommendations would do nothing to deliver extra health workers. "The report does not address the real problems of inadequate funding, duplication, excessive bureaucracy and poor utilisation of current resources," Dr Stitz said. "Insufficient funding means too few operations can be performed and too few training places are available to train enough surgeons of the future. "Surgeons currently working within the public system are prevented from operating on needy patients just to balance budgets."

Dr Stitz said the health system was archaic and impractical. He also said that it would be indefensible to continue to operate under the "current chaos". "Tasks cannot be simply reassigned to other professional groups," Dr Stitz said. "There are insufficient numbers of workers throughout the health system."

The bakery business wants U.S. regulators to stop picking on cherry pies. Cherry pies are the only frozen fruit pies that must meet quality standards set by the Food and Drug Administration. Other fruit pies -- including apples, blueberries and peaches -- are exempt. The FDA created the rule more than 30 years ago. At least 25% of the pie by weight must contain cherries, and no more than 15% of the cherries can be blemished. No one recalls why cherries were singled out. "We likely issued the one standard because we were petitioned to," FDA spokesman Michael Herndon says.

Bakers aren't worried: frozen cherry pie sales reached $22.9 million last year, up 5.7% from 2004, says Information Resources Inc. Bakers say they pack their pies with more cherries than required. Sara Lee Corp. says the fruit makes up between 29% and 43% of its cherry pies. Still, the American Bakers Association is asking the FDA to drop the requirement, but they don't expect a quick answer. An identical plea in 1997 "just fizzled," says Lee Sanders of the bakers association. The FDA says it receives thousands of petitions a year, and it sets no deadline to respond to queries.

For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.

Saturday, January 21, 2006

THE METASTATIC GROWTH OF AN AMERICAN SOCIALIZED MEDICINE SYSTEM

Barry L. Stanton appears at ease in his spacious new office as he discusses key issues at the Prince George's County Correctional Center in Upper Marlboro. But Mr. Stanton, director of the county Department of Corrections for the past nine years, tenses as he bemoans the jail's rising medical costs for inmates. "People get better medical care in jail than I get at home," he says from behind his desk in the jail's new $8 million annex. "If you pick up the phone and you say, 'I am sick' ... they say, 'If it is not an emergency, I will see you tomorrow,'" he says. "Here, [inmates] want to be on sick call right way."

He has seen the Prince George's detention center's average cost per inmate rise from about $83 per day in 2003 to nearly $100 per day last year, while more and more inmates crowd the jail's spaces. Mr. Stanton is not alone in his concerns. Most detention centers in the metro area are dealing with increasing medical costs -- which are covered by taxpayer funds -- and overcrowding, reflecting a national trend.

At the D.C. Jail, inmates routinely are double-bunked in cells designed for one person in most of the 30-year-old facility's housing units. The jail -- one of the oldest detention centers in the region -- can adequately house 2,164 inmates a month, according to a consultant's recommendation in 2004. However, the jail usually houses more than 2,500 inmates a month and sometimes holds as many as 3,555 a month, according to D.C. corrections officials. Most inmates are pretrial defendants awaiting hearings, and their numbers fluctuate as the courts handle their cases. Many inmates also are awaiting transfer to federal prisons, and the remainder are serving sentences.

According to statistics from the U.S. Justice Department and the American Correctional Association, the D.C. Jail's average cost per inmate rose from about $65 per day in 2003 to about $78 per day in 2004. D.C. officials estimate the cost rose to about $86 last year. "I would definitely agree that the cost has risen," says S. Redwood York Jr., who has served as the interim director of the D.C. Department of Corrections since February. "And it is probably a factor of having higher support costs in medical, food service and other inmate needs, combined with the increased population."

City officials attribute the rising costs in part to the jail's exhaustive health screenings, which include voluntary testing for AIDS and tuberculosis. City law requires that the screenings be provided to all inmates, regardless of whether they have been convicted or are being held for trial. Repeat offenders and suspects must be provided with repeat treatments by the jail's more than 140 medical staffers, who work alongside the facility's 687 guards. "We are hoping that someone will understand that we cannot go on doing what we are doing," says Dr. Malek Malekghasemi, the D.C. Jail's associate medical director. "You cannot tell people 'no' because ... inmates have a constitutional right to health care."

For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.

Friday, January 20, 2006

GERMAN PUBLIC HEALTH SYSTEM FALLING APART

If Germany sacked just 1% of its bureaucrats, it could afford to pay its doctors a heap more

Thousands of German doctors threatened yesterday to desert Europe’s most modern health system and work in Britain, rather than put up with declining wages and longer hours. The doctors, many wearing operating masks, marched through the centre of Berlin to besiege the Health Ministry in the first big demonstration against Angela Merkel’s coalition Government. Hospitals worked at half strength and about 50,000 doctors’ surgeries across the country were closed.

“It’s no longer bearable,” Andreas Dahmen, a 31-year-old orthopaedic surgeon, said. “I earn €2,800 [£1,920] a month here after taxes. I’m moving to England where I can earn double that amount for much less work.” In Britain, he said, he could expect to earn £3,000 a month after tax, with the promise of bonuses bringing his earnings to £4,500. The hip specialist was speaking in a sea of placards held aloft by his colleagues, announcing: “England, we’re on our way!” and “If you want to see a German doctor, come to England!”. A third of all German doctors now earn less than €2,000 (£1,373) a month after tax. Junior doctors are using cheap airlines to fly to Britain on a Thursday night, working as a locum for the weekend, and returning on Monday morning. They earn up to £2,000 — the equivalent of a month’s salary. “Recruitment agencies are already trawling our country, hunting for up to 10,000 doctors,” Jürgen-Dietrich Hoppe, the chairman of the German Doctors Association, said. “And I’m sure they’ll get them — English working conditions are so much better.”

Under NHS’s Out of Hours scheme, health trusts can fly in foreign doctors to relieve British GPs who do not want to work in the evenings and at weekends. There is also a desperate shortage in Britain of doctors in areas such as radiology and diagnostics.

The German doctors stopped work yesterday because of government reforms that seek to restrain them from prescribing expensive medicines, cap the individual budgets of surgeries and force hospital administrators to make widespread use of unpaid overtime. Medical staff worked more than €2 billion worth of unpaid overtime in German hospitals last year, and further reforms planned by the Government will put even more strain on them. Another measure would financially penalise doctors who administer costly drugs.

There are 4,127 German doctors registered in Britain, which has become their European destination of choice, ahead of Switzerland and Scandinavia. Some spend their summer holidays in Britain working as locums, others do so for about a year. Far more are weekend commuters and are drawn from across the medical spectrum. “We’re thinking of setting up a mobile anaesthetic unit,” Christof Kouidis, a demonstrator, said. “Working in Britain for a week could cover our practice costs in Germany for the rest of the month.”

The influx of British patients to Germany trying to avoid NHS queues for hip replacements has encouraged German doctors to cross the Channel. Stefan Krukenberg, from Hanover, is planning to replace hip joints in Britain on a freelance basis. “I get €65 for preparing an artificial hip joint — that’s for at least two hours work. Now I’m seriously considering going to Britain on a Friday, preparing three or four hip replacements a day over the weekend and effectively doubling my monthly income.” The only way he would be able to break even under the new tight German costing rules is by preparing 1,000 hip prostheses a month. “And that’s impossible. What we’re doing at the moment amounts in financial terms to a mere hobby. We have to earn the money to live somewhere else.”

The paradox of the German medical crisis is that doctors are now abandoning rural and eastern areas to work abroad, leaving many active but underfunded surgeries in decline. The German Doctors Association estimates that 32,000 surgeries are on the brink of bankruptcy. “We are soon going to have a real shortage of doctors,” Uwe Gremmler, a cardiologist from Peine, said. “Older doctors are taking earlier retirement because it has become impossible to make a living. The younger doctors are moving to Britain and, at the same time, as Germans live longer, there are more and more patients to be treated. The Government should act now before we all disappear to England.”

The spiralling cash crisis in the NHS has already forced two thirds of hospitals to close wards and will soon start directly affecting patient care, health chiefs give warning today. A survey of 117 chief executives of NHS trusts reveals the depth of concern among healthcare professionals about the destabilising impact of wide-ranging government reforms. Three quarters of them say that growing financial pressures brought on by primary and acute care restructuring will affect patient treatment. Almost half of hospital trust managers said that building and refurbishment projects were being delayed, while many trusts were also having to make staff redundant and to introduce recruitment freezes.

The Times understands that the Prime Minister is to order a shake-up of ministers and top civil servants, such is the concern in Downing Street about perceived NHS disarray. It follows six years of unprecedented rises in NHS funding. Mr Blair wants a new junior minister to fend off criticism of the Government’s faltering reform programme and to sell NHS modernisation both to the public and Labour MPs. The health service is braced for even starker financial shortfalls from 2008, when the current round of annual funding increases will stop. The poll of trust executives, conducted by Health Service Journal, comes as nursing leaders also give a bleak warning of massive NHS deficits. Their research suggests that health service debts in England will hit £1.2 billion this year, putting up to 4,000 jobs at risk.

The new minister, who will be charged with promoting the reform agenda in the media, is expected to be imposed on the Department of Health in a reshuffle due within days. The jobs of Jane Kennedy, the Minister for quality and patient safety, and Rosie Winterton, the Minister for health services, are both at risk. The Times understands that a number of senior bureaucrats will also be moved in an attempt to speed up the pace of delivery. It is hoped that the MP will be a more effective deputy to Patricia Hewitt, the Health Secretary, who has struggled to explain the benefits of reforms and had to revise plans to reform primary care trusts.

The uncertainty surrounding unforeseen knock-on effects of the Government’s reforms emerged when ministers decided to review the £1.2 billion redevelopment of Barts and the Royal London hospitals. The last-minute decision, taken after more than six years of project planning, prompted 1,000 doctors to write to The Times earlier this week. They gave warning of the serious impact on cancer and cardiac services for London if the project was downscaled.

Evidence of serious financial problems is supported by 75 per cent of hospital chief executives who said that patient care would be affected by cash shortfalls. The warning comes despite assurances from Ms Hewitt that any cuts should only affect administration. The Royal College of Nursing (RCN), which has been tracking the level of deficits and the impact on staff and services during 2005, confirmed that patient services and treatments were now being disrupted. It found that cost-cutting measures — including freezing job vacancies and use of agency staff — were now having a “direct and detrimental” effect on patients, with operations cancelled, appointments postponed and beds closed. According to documents obtained under the Freedom of Information Act, a total of 81 NHS trusts in financial difficulties have been investigated by KPMG, the acountant. This is far more than the Department of Health acknowledged when it announced the “turnaround teams” of accountants before Christmas. It said that 50 trusts with financial problems would be visited.

The disclosure, and the full list of trusts visited, was obtained by Accountancy Age. They include 20 out of the total of 28 strategic health authorities, 29 primary care trusts, and 33 hospital trusts. A Department of Health spokeswoman last night defended the NHS reform programme. She said that the RCN’s predictions were “back of-an-envelope calculations”, adding that the “turnaround teams” would help to address financial problems centred on a small number of trusts

For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.

Thursday, January 19, 2006

SCOTTISH HOSPITALS SOCK THE VISITORS

When you have been told that your government will look after you, it is a shock to find that it doesn't

The astronomical cost of charges imposed on relatives and friends comforting their sick loved ones in hospital has been laid bare by The Scotsman. Visitors to Scotland's hospitals face a postcode lottery of parking fees. Families also face exorbitant costs contacting their relatives in hospitals using private telephone lines that charge up to 49p per minute for incoming calls, more than the cost of phoning Australia on standard land lines. Charges for patients watching TV add to the overall burden, which can reach £55 a week or more. Families and friends of the most seriously ill on extended hospital stays are having to pay hundreds of pounds to comfort their loved ones.

Colin Craig, whose partner Elaine McFadden was a patient at the Royal Infirmary in Edinburgh from April 2003 to March 2004, when she was battling pancreatitis, racked up £1,600 in parking fees. Widower Henry Robertson paid out £600 over seven months while visiting his dying wife at the same hospital.

The survey of charges highlighted by The Scotsman prompted cancer charities and unions to condemn the practice as immoral, while opposition politicians called on hospitals to review their systems. Ministers have forbidden any health board from using car parking to make a profit, but private companies are subject to no such controls. The most costly parking is at the Private Finance Initiative-built Royal Infirmary, Edinburgh (RIE), where visitors are charged £10 for more than six hours' parking. The car park is managed by Meteor Car Parks for Consort, the firm that built the hospital and runs facilities. The Western General in Edinburgh also charges £7 for more than four hours, while St John's Hospital in Livingston charges £1 per day. At Glasgow Royal Infirmary, where private firm Apcoa runs the car park for owners Impregilo, visitors are charged £1 per hour between 8am and 6pm and a maximum of £1.80 for staying overnight....

However, the Scottish Executive said guidelines issued to health boards should prevent anyone visiting hospital regularly being charged and Lothian Health Board said parking is offered free of charge to relatives, where attendance at hospital relates to trauma or a bereavement. It also offers reduced fees for those visiting hospital on a regular basis over a prolonged period of time.

However, Margaret Watt, chairwoman of the Patients' Association Scotland, said these concessions were unknown to most families and, as a consequence, they were paying out. "It is morally wrong that they are taxing the people who are visiting people who are ill, perhaps seriously," she said. Elspeth Atkinson, Macmillan Cancer Relief director for Scotland, said the experience of being in hospital was stressful enough without having to worry about the extra costs of parking, television or telephone. "Travel costs are the biggest financial burden on people with cancer and that's why Macmillan is calling on the Executive and all health boards in Scotland to ensure that cancer patients do not have to pay for hospital parking," Ms Atkinson said....

Unions representing health workers in Glasgow and Edinburgh have consistently complained about the costs of parking, although the Executive recommends sufficient car parking space and concessionary car parking rates should be available. Apart from the ten named hospitals, all others provide parking for free. However, patients are also being charged to contact patients by phone in many hospitals. Eight hospitals in Scotland have a system installed which is run by the Patientline firm: Crosshouse Hospital in Kilmarnock, Ayr Hospital, Dumfries and Galloway Royal Infirmary, Aberdeen Royal Infirmary, Monklands hospital in Airdrie, Edinburgh Royal Infirmary, Raigmore Hospital in Inverness and Glasgow Royal Infirmary. The firm charges £3.50 a day for watching television, although under-16s get free access, while it is half price for OAPs and long-stay patients. Patients can use the phone for the same cost as a payphone but incoming calls are 39p per minute off peak or 49p per minute at peak times. Phoning Australia from home during the day costs just under 22p a minute.

The Caboolture Hospital fiasco could cost Queensland $67 million in health funding, after the Federal Government yesterday ordered an investigation into possible breaches of the Medicare Agreement. Acting Federal Health Minister Julie Bishop said she was "extremely concerned" about the closure of emergency services at the hospital and the decision to send patients away to see GPs instead.

The State Government yesterday announced it was a step closer to restoring full services at Caboolture, with an agreement for three senior staff from the Mater Hospital in Brisbane to reopen the emergency department on Friday. It had been closed since Monday because of a doctor shortage.

But even as it solved the Caboolture problem, the Government was handed another as Ms Bishop asked her department to investigate the affair. Under the Australian Health Care Agreement, patients who present for treatment at the emergency department of a public hospital must be treated. The hospital is allowed to suggest other "clinically appropriate" service providers "but must provide free treatment if the patient chooses to be treated at the hospital". This agreement also stipulates that "hospital employees will not direct patients . . . towards a particular choice". The contingency plan enacted by the [Queensland] Government to cover the doctor shortage involves less-serious patients being advised to see their GP. Ms Bishop said the referral of more-serious Caboolture patients to Redcliffe and Brisbane may also breach Queensland's commitment to provide "equitable access to public hospital services regardless of geography".

She said the agreement provided for a "compliance payment" which would amount to around $67 million if Queensland failed to meet its obligations. "We're extremely concerned that the Queensland Government appears to be breaching its responsibilities under the Australian Health Care Agreement," Ms Bishop said. "We've provided very substantial funding - $8 billion over five years - and, clearly, this should be used to better maintain the public health system."

For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

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Wednesday, January 18, 2006

DO-GOODER DRUG LEGISLATION CREATES HUGE MUDDLE INSTEAD

And the private insurance fund contributors get lumbered with paying for the problems the legislators and bureaucrats created

With tens of thousands of people unable to get medicines promised by Medicare, the Bush administration has told insurers that they must provide a 30-day supply of any drug that a beneficiary was previously taking, and it said that poor people must not be charged more than $5 for a covered drug. The actions came after several states declared public health emergencies, and many states announced that they would step in to pay for prescriptions that should have been covered by the federal Medicare program.

Republicans have joined Democrats in asserting that the federal government botched the beginning of the prescription drug program, which started on Jan. 1. People who had signed up for coverage found that they were not on the government's list of subscribers. Insurers said they had no way to identify poor people entitled to extra help with their drug costs. Pharmacists spent hours on the telephone trying to reach insurance companies that administer the drug benefit under contract to Medicare. Many of the problems involve low-income people entitled to both Medicare and Medicaid.

In a directive sent to all Medicare drug plans over the weekend, the Bush administration said they "must take immediate steps" to ensure that low-income beneficiaries were not charged more than $2 for a generic drug and $5 for a brand-name drug. In addition, it said insurers must cover a 30-day emergency supply of drugs that beneficiaries were taking prior to the start of the new program.

In an interview yesterday, Dr. Mark B. McClellan, administrator of the federal Centers for Medicare and Medicaid Services, said that "several hundred thousand beneficiaries who switched plans" in December may have had difficulty filling prescriptions in the last two weeks. In California, officials estimate that 200,000 of the state's 1.1 million low-income Medicare beneficiaries had trouble getting their medications. Despite these problems, Dr. McClellan said, Medicare is now covering one million prescriptions a day. With the latest corrective actions, he said, "all beneficiaries should be able to get their prescriptions filled."

In the past, such predictions proved to be premature. New problems appeared as old ones were solved, and some insurers were slow to carry out federal instructions. Since the program began on Jan. 1, many low-income people have left pharmacies empty-handed after being told they would have to pay co-payments of $100, $250 or more. About 20 states, including California, Illinois, Ohio, Pennsylvania and all of New England, have announced that they will help low-income people by paying drug claims that should have been paid by the federal Medicare program. "The new federal program is too complicated for many people to understand, and the implementation of the new program by the federal government has been awful," said Gov. Tim Pawlenty of Minnesota, a Republican. On Saturday, he signed an emergency executive order making the state a "payer of last resort" for the out-of-pocket drug costs.

The Bush administration said it was rushing to provide insurers with correct information about the extra subsidies available to low-income people enrolled in their plans. "We sent files to all plans providing complete information on dual-eligible beneficiaries" entitled to both Medicare and Medicaid, Dr. McClellan said. "The plans now have all the information in one place." The new drug benefit is the most significant expansion of Medicare since creation of the program in 1965.

A one-minute trip to hospital became a 44-minute ordeal for a woman suffering serious head and chest injuries, as the human cost of the Caboolture hospital emergency department closure was revealed yesterday. On the first day of the Beattie Government's contingency plan for Caboolture, a fatal accident just 250m from the hospital's entrance resulted in a lengthy ambulance trip to Redcliffe for a 50-year old female patient. And it forced a 77-year-old with more serious injuries to wait for more than an hour to be airlifted to Brisbane. A 97-year-old female passenger, who had been receiving treatment at the hospital, died in the accident.

After weeks of denials, the State Government admitted yesterday that emergency services at Caboolture were effectively closed as a result of a statewide doctor shortage. The Caboolture Hospital's emergency department was closed from 6am yesterday because of a lack of staff. The fatal accident at the entrance to the hospital happened at 3.45pm after a white Holden Barina hatchback, in which the three women were travelling, and a white Holden Rodeo collided. The 97-year-old woman, who died in the crash, had been receiving treatment at the hospital. The 50-year-old female driver of the Barina was transported by ambulance to Redcliffe Hospital. The 77-year-old seriously injured passenger in the Barina was airlifted to Royal Brisbane Hospital.

Last night The Courier-Mail was advised it took an ambulance 44 minutes to transport the injured female driver to Redcliffe. But it is believed the woman, suffering from head injuries, broken ribs, and chest injuries, requires a high-dependency bed not available at Redcliffe Hospital, and will have to be transferred to either the Royal Brisbane or Princess Alexandra Hospital.

Australian Medical Association Queensland president Dr Steve Hambleton said he was advised a doctor from the Caboolture Hospital assisted paramedics at the accident. "A tragedy like this drives home the importance of quality services in large communities that are growing fast," Dr Hambleton said. "It may well have been that these people would have needed air transport anyway. "It just highlights how unpredictable our lives are, and the need for quality services." Dr Hambleton said the Queensland Government now had no choice but to "fix" the problems with its public hospitals.

Opposition Leader Lawrence Springborg described the car accident victims as "the tragic human face of government spin". Late yesterday, Acting Premier Anna Bligh announced a temporary deal made with the Mater Hospital to provide doctors so the emergency department could be reopened in coming days. Health Minister Stephen Robertson insisted the two patients injured outside Caboolture Hospital had received appropriate care despite the closure. He said the woman transported to Redcliffe had received immediate attention from paramedics, and the person airlifted to Brisbane would not have been treated in Caboolture because of the nature and extent of her injuries.

But Caboolture's former emergency department director Sylvia Andrew-Starkey said the woman "would have been stabilised at Caboolture" if the department had been operational....

Mr Robertson yesterday admitted the Caboolture Emergency Department "is, in fact, closed" after claiming since late last year it would remain open and services would simply be scaled back. He said five people had presented at the hospital yesterday. Three had been told to go to a GP, despite Mr Robertson's claim earlier this month that "no one's going to be turned away". Despite previously insisting that the department would be staffed by a senior doctor during the day and a junior doctor at night, Mr Robertson admitted there had been no emergency doctor present to see the other two patients.

For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.

Background

Postings from Brisbane, Australia by John Ray (M.A.; Ph.D.) -- former member of the Australia-Soviet Friendship Society, former anarcho-capitalist and former member of the British Conservative party.

This blog gives a lot of attention to events in Australia and Britain -- places where there already exist systems similar to the one most likely to befall the USA if the Democrats get their way -- "Free" medical care supposedly available to all through government hospitals but with a competing private sector as well. The Canadian system is considered too Soviet to provide a likely model for the USA

TERMINOLOGY: Many of my posts concern the very instructive state of socialized medicine in Australia. Like the USA, Germany and India, Australia has a system of State governments which have substantial independence from the central (Federal) government and it is they who are mainly responsible for "free" health services. It may therefore be useful to some for me to note the standard abbreviations for the States concerned: QLD (Queensland), NSW (New South Wales), WA (Western Australia), VIC (Victoria), TAS (Tasmania), SA (South Australia).

For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Conservatives do NOT object to helping the poor. Government welfare legislation in aid of the poor was in fact first introduced by conservatives -- Bismarck and Disraeli in the 19th century. What conservatives want is for the help to be delivered in a sane manner. And anyone who thinks that government bureaucracies can run hospitals well is completely out of touch with reality.

One of the oldest "free" public hospital systems in the world is that in the Australian State where I live: Queensland. It dates from 1944 (Britain's NHS began in 1948). So its advanced state of decay reveals well where the slow cancer of bureaucracy ends up. It now has three "administrative" employees for every medical employee. All those clerks are really good at curing people, I guess! Frequent bulletins on the flailing but ineffectual attempts to "fix" the system will appear here -- as well as bulletins on the dreadful things it does to patients and the long waits they endure.

On all my blogs, I express my view of what is important primarily by the readings that I select for posting. I do however on occasions add personal comments in italicized form at the beginning of an article.

I am rather pleased to report that I am a lifelong conservative. Out of intellectual curiosity, I did in my youth join organizations from right across the political spectrum so I am certainly not closed-minded and am very familiar with the full spectrum of political thinking. Nonetheless, I did not have to undergo the lurch from Left to Right that so many people undergo. At age 13 I used my pocket-money to subscribe to the "Reader's Digest" -- the main conservative organ available in small town Australia of the 1950s. I have learnt much since but am pleased and amused to note that history has since confirmed most of what I thought at that early age.

I imagine that the the RD is still sending mailouts to my 1950s address!

NOTE: The archives provided by blogspot below are rather inconvenient. They break each month up into small bits. If you want to scan whole months at a time, the backup archives will suit better. See here or here